Health Care and Public Health
US Air Force personnel jog on Waikiki Beach (USAF photo)
Health care reform is clearly a complicated subject, but I think the single most compelling isolated factoid in favor of reform is the basic reality that Americans spend wildly more on health care than any other developed country and yet lead shorter lives than the residents of most developed countries. Now, clearly, there’s a bunch one could say on this subject. But one common counterargument I’ve never understood is this line from Gary Becker:
National differences in life expectancies are a highly imperfect indicator of the effectiveness of health delivery systems.for example, life styles are important contributors to health, and the US fares poorly on many life style indicators, such as incidence of overweight and obese men, women, and teenagers. To get around such problems, some analysts compare not life expectancies but survival rates from different diseases. The US health system tends to look pretty good on these comparisons.
For one thing, the US actually doesn’t look especially good on those comparisons.
But for another thing, the reality that delivering health care services is not a very effective way of delivering good health outcomes is itself a powerful point against the American system. After all, one reason we spend so much on health care is that spending a huge proportion of national income on making people healthier seems like a perfectly reasonable idea. But if it turns out that spending money on health care isn’t an effective way of promoting good health outcomes, then that means we’re doing something badly wrong. We should, it seems, be spending less on health care and more on nutritious food and gym memberships and schools (educational attainment is highly correlated with good health outcomes) and anti-poverty spending.
To put it another way, imagine a right-of-center economist arguing about foreign aid. He’d point to the fact that Africa’s gotten more aid than East Asian countries that have done much better as a reason to be skeptical that our aid programs are effective. If I turned around and tried to say “no, no, it’s not that our aid programs don’t work, it’s just that foreign aid isn’t very useful in promoting economic growth” I don’t think anyone would be very impressed by that counterargument. The legitimate reason to spend vast sums of money on health care would be to reap large health benefits. The fact that we’re not seeing large health benefits indicates that we’re doing something wrong.
41 Responses to “Health Care and Public Health”
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June 23rd, 2009 at 2:41 pm
It’s annoying when people try to blame excessive American health care cost on American lifestyles. Sure, we’re pretty much a bunch of lardasses, but why don’t they ever talk about how much the rest of the world smokes? And drinks? And drives drunk?
June 23rd, 2009 at 2:48 pm
but why don’t they ever talk about how much the rest of the world smokes? And drinks? And drives drunk?
The rest of the world has public transportation, duh. They drink more because they know they don’t have to drive!
June 23rd, 2009 at 2:48 pm
The fact that Becker is from the “Chicago School” should compel any serious person to ignore him.
June 23rd, 2009 at 2:50 pm
One issue that gets almost no play is the massive amount of money we spend in the last 6 months of life. We spend money at the wrong time, skimping when small amounts of money can do a lot of good and lots of money when the patient is close to death.
June 23rd, 2009 at 2:51 pm
DeLong makes another, more economist-minded point after quoting Paul Kugman on the same debate of “what to measure”:
Becker and Mankiw are pissing on our legs and telling us it’s a cool summer shower.
You can also point to Timothy Noah’s nice little piece about the underlying exceptionalism of the American health care debate: the Taiwanese started their reform process with people saying ‘let’s do what the Americans do, best healthcare in the world, etc.’ and came to the conclusion that the Americans have a market, not a system, and that that kind of market was unacceptable for them.
The market model is what leads to an inherent pathological character throughout healthcare in the US. An analogy: you can have the best termite exterminators in the world, but it’s better to build homes that are resistant to termites in the first place.
June 23rd, 2009 at 2:52 pm
Good point, Matt.
In the end, the bottomline is that at best, if you adjust for everything it may turn out we aren’t getting substantially worse health outcomes than our peers. But we also aren’t getting substantially better health outcomes, so what exactly is the purpose of expending all these additional resources?
June 23rd, 2009 at 2:53 pm
Or what DeLong said.
And yes, it is odd these economists appear not to be thinking like economists on this issue. I guess they just can’t bring themselves to accept this is a pretty straightforward market failure.
June 23rd, 2009 at 2:58 pm
One issue that gets almost no play is the massive amount of money we spend in the last 6 months of life.
I think it’s getting some play now, but the inherent problem is that Medicare has always been portrayed as the feast after the famine: you’ve sucked up shitty private insurance your working life, grandpa, and you’ve managed to make it to retirement age, so the healthcare free buffet starts now.
As I said in an earlier thread, it becomes more politically viable to address end-of-life heroic measures when retirement is no longer seen as the point at which they no longer have to worry about continued coverage or pre-existing conditions.
June 23rd, 2009 at 3:01 pm
There is no health care system which is going to convince Americans to get off the couch, and when they are on the couch, to eat edamame instead of potato chips. Or convince Amricans to not become homicide or car accident victims.
Now, it may be possible to convince Americans to make such changes, but that doesn’t have anything to do with any health care proposal.
June 23rd, 2009 at 3:06 pm
Will Allen,
That’s the freakin’ point. There is only so much spending on health care can do to affect health outcomes, which in turn helps explain why spending a bunch more than our peers on health care actually isn’t getting us better health outcomes.
June 23rd, 2009 at 3:24 pm
Will,
I’d never heard of edamame until now, so I’ll pick some up next time I’m buying arugula at Whole Foods (like all good liberals). So hey, you’ve convinced one! Keep it up.
June 23rd, 2009 at 3:24 pm
I think the best health comparison would be Australia, which now boasts the second longest life expectancy. Yet they are also now as fat as we are, and they drink and smoke much more. They live longer with a less healthy lifestyle by all measures. And they spend much less money doing it. Something’s working down under.
June 23rd, 2009 at 3:31 pm
This is exactly right – we should be slashing spending (as a country) on health care and spending it on things that would actually lead to better health outcomes.
Too bad I have never seen any politician propose such a policy. Certainly none of the current health care proposals in Congress and from Obama don’t do anything of the sort.
June 23rd, 2009 at 3:32 pm
Adam, Edamame is soooooo much tastier than the typical Amarican salty snack, is much more filling, hugely more nutritous, and at a place like Costco you can buy a huge amount, for next to nothing, which can be stored in your freezer for a very long time. This is a bar snack in Japan, to be eaten while swilling beer.
June 23rd, 2009 at 3:33 pm
Remember it isn’t how long you live, it is how well you live.
If I stay in a coma from when I am 62 until I am 87 then I didn’t have a very good life for my last 25 years.
I don’t know how to measure quality of life years but it is a better way to measure outcomes than just recording when I die.
June 23rd, 2009 at 3:39 pm
O.K., DTM, you go get elected to Congress by telling 75 year old fat people with diabetes, heart conditions, and arthritic knees that they won’t be getting what they have come to see as their entitlement, because in aggregate it just isn’t worthwhile.
June 23rd, 2009 at 3:39 pm
Certainly none of the current health care proposals in Congress and from Obama don’t do anything of the sort.
Hack harder, Al! I mean, you’re surely not so dumb to think that any reform can be achieved without up-front costs, right?
Please, tell us how you reduced your heating bills by closing your eyes and pretending that you insulated your attic.
June 23rd, 2009 at 3:39 pm
I’m with you Will, Edamame rocks. Best bar snack ever.
June 23rd, 2009 at 3:42 pm
One day, Will Allen might actually show us that he’s acknowledge the arguments here about how to address the “free retirement buffet” model of Medicare.
Or he might just repeat the same old shit over and over and over.
June 23rd, 2009 at 3:45 pm
What are the big problems with American lifestyle?
We eat too much in general, and in particular too much meat and too much sugar.
We’re sedentary.
We’re stressed out, which causes general inflammation which helps lead to cancer, heart disease, and diabetes.
It seems to me that all of these can be substantially addressed by policies we should enact anyway. First is the pricing of CO2 emissions, which will make meat, driving, and large homes in the ‘burbs more expensive relative to plant-based food, walking/cycling/walking-to-transit, and smaller more efficient homes closer to where we work. Second, we should end corn and soy subsudies, which will also make meat and sugar (in the form of corn syrup) more expensive and will decrease the omega-6 fatty acids in our diet (which cause increased production of inflammatory hormones). Third, we should have federally-mandated vacation time, which will all people to decompress; related to this is maternity (and paternity) leave, which is good not only for the development of children but also seems to be a basic question of being humane to our mothers and fathers that a rich country like the U.S. can easily afford. Pricing carbon (and better land use policies) will also reduce the time people spend getting stressed out in traffic jams, which is probably the most easily avoidable daily stressor most people face (stress from relationships and work–there’s probably little we can do much about on a policy level aside from more vacation time and better support for people raising children). Fourth, people are stressed out as well due to lack of financial security, especially the threat of bankruptcy due to medical bills, which will be a thing of the past with universal public health insurance.
June 23rd, 2009 at 3:48 pm
I mean, you’re surely not so dumb to think that any reform can be achieved without up-front costs, right?
I’m sure that some reforms would have up front costs, and some reforms wouldn’t. But I have yet to see a reform (with or without up front costs, with or without expanding the government portion of health care costs) that actually contains cost saving measures that would shrink the portion of GDP that goes to health care.
June 23rd, 2009 at 3:50 pm
Those aren’t arguments, psyd in NC, unless you consider “and then a miracle happens!” to be an argument. People who have been trained to think that health care rationing is for other people aren’t going to be untrained that easily. Telling such a 75 year old today to do without what the 75 year old had yesterday, because 40 year olds will have it better, isn’t going to work.
June 23rd, 2009 at 3:55 pm
“Americans spend wildly more on health care than any other developed country and yet lead shorter lives than the residents of most developed countries”
The above is a fact. It may also be a point in favor of reform. But that does not make it a point in favor of the currently proposed reforms.
The real answer is staring us in the face: end the tax subsidy for employer sponsored healthcare benefits. This would likely reduce consumption by 20% with no negative implications for Americans’ health. Then we could devote some of the savings (through subsidies) to covering the uninsured.
June 23rd, 2009 at 3:57 pm
Telling such a 75 year old today to do without what the 75 year old had yesterday, because 40 year olds will have it better, isn’t going to work.
That’s a completely dishonest rephrasing of what I’ve said, and either you know that you’re being dishonest or you’re too fucking stupid and stubborn to work it out.
June 23rd, 2009 at 3:58 pm
Free-market jihadists like Becker are beyond stupid when they try to give any kind of opinion on the real world. Read again what he says:
The obvious question is: why the hell would “many life style indicators” create a bias on life expectancy (so severe that it is “highly imperfect”) but wouldn’t affect at all “survival rates from different diseases”. The only reason is that Becker has found some measure where “the US health system tends to look pretty good”.
If you ignore all the catastrophic failures that resulted from the teachings of the Chicago School and instead focus on the number of not-really-Nobel prizes, that Economics department looks pretty good.
June 23rd, 2009 at 4:02 pm
I quote:
“As I said in an earlier thread, it becomes more politically viable to address end-of-life heroic measures when retirement is no longer seen as the point at which they no longer have to worry about continued coverage or pre-existing conditions”
Someone already at the all you can eat buffet isn’t interested in hearing well reasoned arguments about why it now can be closed, and the people now at the buffet are in the most sought-after electoral group.
June 23rd, 2009 at 4:09 pm
Will Allen,
Older people, like everyone else, care about health outcomes, not health spending per se.
June 23rd, 2009 at 4:10 pm
Will Allen, taking more money from the rich and squeezing pharmaceutical and insurance companies profits would prevent your nightmare scenario of rationing. Instead of deciding who has to die, we just have to decide how many yachts Pfizer CEO needs.
June 23rd, 2009 at 4:31 pm
Again, Will Allen is either dishonest or really fucking stupid.
June 23rd, 2009 at 4:51 pm
I am all for drastic healthcare reform. But there seems to me to be something fishy about MY’s counterargument to Becker in this post. As I read him, MY wants to say that the fact that U.S. healthcare outcomes are worse than outcomes in comprible places, that means the U.S. healthcare system is not as effective at doing its job–which is to produce good health outcomes. Seems to me that Becker’s line of thinking suggests that the U.S. healthcare system is good at *improving* health outcomes, so to speak. Just because people in the U.S. are sicker and die younger than people elsewhere doesn’t mean that the U.S. healthcare system isn’t helping people with their health (e.g. doing a better job fixing them when they get sick) more than elsewhere. (Though I doubt it is.) If the U.S. healthcare system is dealing with obstacles to good health outcomes that other countries are not dealing with, that might suggest that it’s doing more to promote good health than the healthcare systems in other countries. The claim that the U.S. has a higher sickness “clearance rate” suggests that this what is going on. (MY denies this claim of Becker’s, but grants it for the sake of argument.)
If this is this situation, and the U.S. healthcare system is as good or better than elsewhere at making sick people better, then you might want to focus on helping people not get sick in the first place by encouraging exercise and vegetables. But the fact that the healthcare system doesn’t do a good job at addressing these kinds of problems is, at least arguably, not a problem with the healthcare system. That’s not part of its job (arguably).
I think it’s rhetorically useful, but a bit of a distraction to focus on whether the U.S. healthcare system is more or less effective than other healthcare systems. In my book, the most important reason to fix the healthcare system is that it is really unjust for an affluent society to leave a sixth of its population without healthcare. The second most important reason to fix the healthcare system is that it is hugely expensive. The important lesson from europe is not that the US can have better healthcare for less money. The important lesson is that the US can have perfectly good, justly distributed healthcare for less money.
June 23rd, 2009 at 4:51 pm
The first step to bringing the quality of health (not health care, health) in this country up is to cut through the rididuclous fallacies floating around about nutrition. If people were properly educated about the effects of a diet high in refined carbohytdrate, I have no doubt that we would see a dramatic decrease in cases of Obesity, Diabetes, Heart Disease and Cancer. The science behind this statement is sound. Refined carbohydrate and corn is killing our country, and every other civilized country for that matter.
But what do we hear day in and day out? Cut fat. Eat smaller meals. Self-restraint. Ad nauseam.
June 23rd, 2009 at 6:01 pm
Yes, Psyd in NC, and old people think being told that can’t have something, even if there is a small chance that it will work, is a bad outcome, especially when the current state of affairs is such that they are rarely told that they can’t have something. Must everything be explained to you in such a basic fashion, you drooling, slack-jawed, half-wit?
June 23rd, 2009 at 6:06 pm
Why of Why, if you are the sort of person who thinks that there is a place on earth where health care is not rationed, or that there could ever be a place where health care is not rationed, well, further discussion is pointless.
June 23rd, 2009 at 6:17 pm
Re: The rest of the world has public transportation, duh. They drink more because they know they don’t have to drive!
Nonsense. There are plenty of drivers in Europe and (certainly!) Canada. Many countries do have much more stringent DUI laws than the US, and public transportation does play role there in giving people an alternate means of travel home from the bar. But the health dangers of excess alcohol use are hardly limited to drunk driving. In fact that is one of the lesser issues.
Re: One issue that gets almost no play is the massive amount of money we spend in the last 6 months of life. We spend money at the wrong time, skimping when small amounts of money can do a lot of good and lots of money when the patient is close to death.
One problem here is how do we know when a person is six months from death? Such predictions are far from foolproof. In many cases they are about as accurate as predictions about the weather six months out. Also, a lot of that expense involves nothing more than palliative care and I’m not sure how we can skimp on that unless you advocate turning the dying out into the streets to expire.
June 23rd, 2009 at 6:18 pm
Will Allen, I talked about your nightmare scenario resulting from a public plan. Of course there is always rationing in health care. Taking money from the rich and insurers would actually make rationing less severe than it is today.
But I agree with you, further discussion with you is pointless, because you only keep repeating “you will make some people die!!!”. With this logic, any health care plan (including the current system) is mass murder.
June 23rd, 2009 at 6:30 pm
why oh why, you hallucinated something about a nightmare scenario. I merely observed that very few people are willing to be honest enough as to identify who will die first in their preferrred rationing scheme. Yes, having a discussion with someone who is suffering from hallucinations is likely pointless.
June 23rd, 2009 at 7:31 pm
“One problem here is how do we know when a person is six months from death? Such predictions are far from foolproof.”
They aren’t foolproof, but they are pretty good. When my father was given six to twelve months, he lasted eight. When my mother was given three to six, she lasted five. My brother’s case was a very rare form of cancer without good data. He was given six to twenty four months and lasted nine. My father did the average treatment and spent $500K. My mother did extreme treatment and spent $1M. My brother’s cancer was untreatable, so he hardly spent any money. Just morphine and the occasional biopsy, about $30K. When the morphine wasn’t enough and they refused to give him Dilaudid, he bought a lethal dose of heroin and permanently ended his treatment. It’s hard to tell a family member that it’s time to give up, but $10K per day to live a life of misery doesn’t make much sense.
June 23rd, 2009 at 7:44 pm
Thanks for the Air Force jogging porn Matt. I don’t think the AF was any more diverse in 1980 when that was taken than when my dad retired in 1974.
June 23rd, 2009 at 8:20 pm
“We should, it seems, be spending less on health care and more on nutritious food and gym memberships and schools (educational attainment is highly correlated with good health outcomes) and anti-poverty spending.”
Who’s the “we” here? My circle of friends spends a lot of money on this stuff. Should they pay for someone else’s, too?
I spend very little on these things, on the other hand. Who should pay for my gym membership? Who should pay to upgrade me from standard macintosh apples to the ones that cost $4 a pound?
And, uh… why should they? The reason that I don’t have money for such things is that I spend it on beer and a bigger house.
So I die 10 years earlier. Why is that anyone else’s problem?
June 23rd, 2009 at 8:21 pm
Re framing the argument on this point: For the results we get from our healthcare system, the US is flat out LEAVING MONEY ON THE TABLE. Advocates of single-payer and/or a public plan should get out there and repeat nonstop that this is a way for us to STOP LEAVING MONEY ON THE TABLE.
June 23rd, 2009 at 8:39 pm
I’m going to go with “really fucking stupid” for Will Allen, though the earlier diagnosis of “borderline Asperger’s and thus unable to compute things that diverge from his preconceptions” might be another explanation.